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In a doctor’s office, the solution to a problem is not always a matter of science. “Many times people come to the appointment with a complaint of physical pain, but if I go deeper, I end up realizing that there’s a whole context for that pain.” Cristiano Figueiredo is a family doctor at the Downtown Family Health Unit (USF) and recognizes that he doesn’t always find in medical science or a drug the cure for the patient’s problem.

“It could be an elderly gentleman who lives alone without family and who has lost all his neighbors. Or it’s someone who has lost his job and feels lost. Prescribing an antidepressant will not totally help. It may be necessary, but that alone will not work. We have to be curious and understand what is really going on in the person’s life. And when we understand the context, a whole range of new possibilities open up.”

This is what the social prescription project that the doctors at this health center have been applying to their patients since 2018 proposes.

Cristiano Figueiredo believes that the different activities that the community offers are an answer to loneliness and isolation. Photo: Rita Ansone.

There are now more than a thousand beneficiaries of this social prescription model. And what is this: instead of prescribing medication or clinical methods, it prescribes social actions such as workshops, socializing or even physical exercise.

A model already applied in other countries and brought by Cristiano Figueiredo to Portugal. A real team effort between the health center, community services and the social sector, to respond to various social and emotional problems, such as isolation, depression or anxiety.

So says Maria Patrício, 74 years old. “Better a gym class than a pill,” she says, now a regular at the Senior University in Rua da Prata. “I’m a very anxious person and I usually sleep poorly, but with the gym classes I already feel much better and my sleep has improved” – she smiles with the memory.

Today Maria is a woman with more agility, in a better mood, and is already capable of taking a walk between Avenida Almirantes Reis and Baixa with her son Pedro. He, who at 45 years old, accompanies her in gymnastics and more: he attends history and psychology classes to occupy a time that, before, passed very slowly and without any stimulus.

With a brain disease that resulted from a fall when he was nine months old and caused him to lose his sight, Pedro cannot lead an autonomous life. But since he joined the Senior University his life “stopped being monotonous” and now he always has a reason to leave home. “I’m in a better mood.” And no medication was needed: he and his mother only needed a different piece of advice from the doctor at the USF downtown.

Maria and Pedro Patrício attend Senior University classes and already feel improvements in their quality of life. Photo: Rita Ansone.

Looking at the patient as a whole… and with everyone’s help

It all starts as usual: with a doctor’s appointment. But instead of the doctor asking only what hurts or worries the patient, and reaching for the stethoscope, what he does is an integrated analysis of the patient’s social context.

Then the user is referred to a social worker. In Portugal, this role falls to the social worker, but in other countries where social prescription is applied the most appropriate term is link worker – a kind of guardian that can be someone from the Town Hall or Parish Council, for example.

It sounds simple and logical, but for it to work and have a real impact on the users, there needs to be a well-articulated structure between the health center, the social worker and the answers that the community offers.

“There has to be a closed circuit of action between primary health care, social worker and community resources, and vice versa,” explains Andreia Coelho, the social worker who has been with the project since the beginning.

These sectors had always worked for the same population and sought the same solutions, but were working in isolation.

On the left, Cristiano Figueiredo, the physician who brought the Social Prescription approach to Portugal, on the right, Daniel Morse, who is trying to do the same in the United States. Photo: Rita Ansone.

“There was a need for these sectors to meet, because they don’t normally work together, despite serving the same population and being based in the same neighborhood,” says Cristiano Figueiredo. He, who brought the concept of Social Prescribing to Portugal after having a professional experience in the United Kingdom, a country that is a pioneer of this approach and that integrated Social Prescribing into the National Health Service in 2019.

The first step was then to bring this separate city together. And in mid-2018, the doctor began to promote several meetings between his health center, social workers and various associations and institutions of the Downtown. He reports that the adhesion was very large and it was soon realized that there were several social responses that the health center could not offer, but that were right next door, in the neighborhood.

Examples are the gymnastics classes and the senior university, which Maria and Pedro attend, but also volunteering, cooking workshops or literacy classes. All new recipes for the same users.

Because if a doctor asks “what made you feel happy as a child” and “if the user answers ‘music’, maybe now taking music lessons can be a solution to feel less lonely,” says Daniel Morse, director of Social Prescribing USA, who has been working with UK professionals to implement this project in the US, and who was visiting Lisbon.

However, it is important that when the patient comes to the social worker, he or she comes “clinically stable from a mental health point of view,” says Andreia Coelho. The prescribed activities have the purpose of improving the state of health and if medication is reduced or withdrawn, “it’s a gain at all levels, both for the user and the health center, and for the national health service,” which is saving resources.

But the work shouldn’t end with the prescription. The social worker also accompanies the user in participating in the activities, insofar as attendance and absences are monitored. “For example, at the Senior University, they send us a chart with the attendance and absences, and in case of absences we try to understand what is going on and find other solutions,” says the social worker, stressing the role of articulation between the sectors so that the process doesn’t get lost.

The increasingly frequent meetings to articulate the three sectors and to fine-tune strategies, the creation of a computer system for the referencing of Social Prescription, and a list of existing solutions in the community have led to the consolidation of a project that started as a pilot project in the USF da Baixa. Today, it has already been extended to five other health centers: Almirante, Sétima Colina, Penha de França, Mónicas, and Ribeira Nova health centers..

The challenge of caring in a place of many cultures

The location of the USF da Baixa in Martim Moniz and the fact that it serves the parishes of Santa Maria Maior, Arroios, Penha de França, São Vicente and Misericórdia means that the population it serves is quite diverse and, consequently, with different needs that require personalized responses.

“We serve 94 different nationalities and I would say that 30% of the users are migrants and most of them are from Southeast Asia. We started to notice that these people suffer from chronic diseases, like diabetes or hypertension, which are directly related to food,” says family physician Cristiano Figueiredo.

Once the diagnosis of this population was made, the team at USF da Baixa realized that the medical staff was not the best suited to help these migrants. “We wanted to recommend a healthy diet based on the Portuguese diet, but we know it’s not the most appropriate for these people, and we don’t know the South Asian diet either.”

Solution? Refer these users to workshops on healthy eating according to the cuisine of their country, at the Cozinha Popular da Mouraria – a project to share the world’s cuisines. “With this knowledge, these migrants can cook healthy recipes based on their culture,” adds the doctor.

The Cozinha Popular da Mouraria and the NIALP are two associations that, with the USF da Baixa, help in the integration of migrants. Photo: Rita Ansone.

Another characteristic of these migrants is that many are pregnant women or young mothers. Coming from a far away country and from a very different culture and language, many of them come alone or spend their days unaccompanied because their husband works outside the home. Feelings like loneliness and depression start to become frequent among these women.

And here, too, doctors and social workers have sought answers that could meet the cultural specificities. In partnership with NIALP (Intercultural Association of Lisbon), these mothers attend a Pregnancy Club that aims to give them the necessary tools to take care of their children, as well as put them in contact with other mothers from the same culture. It is a common sharing space so that the loneliness of being pregnant in a different country does not feel so much in their lives.

But treating those who come from abroad can also involve prescribing the Portuguese language.

Fanta Sonco immigrated from Guinea-Bissau for treatment of a vascular problem. During medical consultations, it was realized that Fanta could not read or write and that, besides the bureaucratic problems associated with those who arrive in Portugal, this was making it even more difficult for her to integrate and be independent in Lisbon. So the doctor prescribed that this 39 year old Guinean woman should join a mentoring program of the CNAIM (National Center of Support to the Integration of Migrants) and attend literacy classes at the Marquesa de Alorna School.

Fanto came from Guinea-Bissau and could not read or write. Photo: Rita Ansone

Andreia Coelho considers Fanta a “success case” of Social Prescription. Before going to classes, he had a very precarious job and worked only two hours. Now, she’s got a job and better wages.

In addition, the improvements in her well-being are visible.

“When I met her she was a very downcast person, and now she smiles more,” says social worker Andreia Coelho. Cristiano Figueiredo also notices “better levels of well-being, fewer trips to the Health Center and a more autonomous and integrated Fanta in society.

For Fanta, it is a “pride to be able to sign his name, send messages and be able to read documents. Combining two jobs with evening classes, she now speaks Portuguese much better and has an easier time in a country that was so much stranger to her until recently.

The recipe for fighting loneliness

One of the groups that benefits most from this project is people over 55. As a rule, they are ending their working life, have been laid off, or live alone. These factors lead them to feel without a purpose, lost and alone.

“Some of these people are very old and live in buildings where there is only Airbnb, feeling very lonely,” says Cristiano Figueiredo.

That’s why, for these people, the classes at the Senior University – which can be history, crochet, painting, gymnastics, computers, or languages – are a way to feel more active and even prevent other diseases. “We have some cases in which users show some signs of forgetfulness. It’s not dementia nor is it serious, so attending these classes can be an excellent form of prevention.”

Prevention or occupation of time are some of the objectives of the Senior University and Pedro Patrício already notices the results of these classes since, as he said at the beginning of this story, life has become much more interesting since he became a student at this institution.

At the USF da Baixa, the Social Prescription has existed since 2018 and has already covered about a thousand users. Photo: Rita Ansone

One of the other partner institutions of Social Prescription is Pedalar Sem Idade (Ride without Age). With roots in Denmark, this project accomplishes two goals: on the one hand, elderly people and people with reduced mobility have the opportunity to ride a bicycle and walk around the city; on the other hand, these rides are provided by volunteers who may also be people who feel lonely.

Both participants see their lives improved: “The first ones have the opportunity to ride their bikes, getting some exercise and at the same time getting to know Lisbon in a different way. And the volunteers find in these rides a way to meet different people, feeling less lonely,” explains doctor Cristiano.

Pedalar Sem Idade arrived in 2018 and raised passengers in Lisbon. Photo: Inês Leote.

The means to reduce emergency room crowding?

Users, health professionals, and social workers recognize that this new form of prescription is an innovative project that unites various sectors and has had a very positive impact on the community they serve. In fact, “now it’s hard to imagine the downtown FHU without the Social Prescription”, confesses Cristiano Figueiredo.

This approach is being evaluated by the National School of Public Health, which soon joined this project. Sónia Dias, president of the institution, explains that monitoring is being done in order to understand which factors facilitate the implementation of Social Prescription.

“We are looking at three levels: the issues of quality of life, well-being, physical and mental health and also the satisfaction of those who are referred; the issues of articulation between sectors and the issues of the impact of this new practice on the sustainability of the National Health Service,” says Sónia Dias.

Sónia Dias, president of the National School of Public Health, makes a positive assessment of the impact of Social Prescribing. Photo: DR.

This last parameter is being studied since many of the referred users are also “over users of health units and social responses”. In this way, the researcher also believes that by maximizing the resources available in the community that are better suited to people’s needs, the use of health care will decrease, contributing to the sustainability of the system.

“There are studies in the UK that show that a good Social Prescribing initiative can reduce, for example, emergency room use,” says Sónia Dias.

Social Prescribing in other countries:

Although it is difficult to measure the impact and success of Social Prescribing, since the evaluation is qualitative and often the results are shared by the users, there are already some studies that show its effectiveness in the UK – a country where this approach is widely consolidated in Health Centres.

A Social Prescribing programme in Shropshire, evaluated between 2017 and 2019, found that users referred to Social Prescribing reduced their GP visits by 40% compared to those who did not benefit from this approach. This study also showed that significant improvements were reported in terms of wellbeing, user autonomy and loneliness.

In 2017, the University of Westminster published a study in which they identified a 28% reduction in GP visits and a 24% reduction in emergency room visits for those who received Social Prescribing.

The result of a partnership between volunteers and community associations, Rotherham’s Social Prescribing Service has resulted in 8 out of 10 people referred for prescribing using the NHS less: there were fewer hospital admissions, visits to the emergency room and visits to the GP.

And a study of a social prescribing project in Bristol found that improvements were noted in anxiety levels and in the perceived health and quality of life of social prescribing recipients.

In Portugal, and in the case of the USF da Baixa, there are still no such studies, but a doctoral thesis is being conducted, coordinated by Sónia Dias, to assess the impact of this project, whose results will only be available in 2024.

During the course of the research, some interviews with users have already been conducted, revealing a very positive assessment – although there are still no concrete quantitative data, such as a decrease in consultations or drug prescriptions, since “Social Prescription does not yet have enough time to allow for an impact assessment,” says the director of the National School of Public Health. But there is a perception that this is happening.

“We can say that those who have started to attend the Senior University feel better and more active. The same is true for migrants: “they feel less alone and more integrated,” sums up Cristiano Figueiredo. “After the acceptance process, which can sometimes be strange to see an activity prescribed and not a medication, the feedback is very positive.”

But there are more positive aspects that result from this project: it’s that the partner institutions are creating synergies among themselves to provide answers to other problems. “We are seeing the duplication of responses, to the extent that the partners are also starting to work in a network, which allows them to have greater articulation and knowledge of the various areas in which they provide services. This was also a great indirect added value of this initiative,” says Sónia Dias.

By bringing together common solutions and wills, Social Prescription “allows us to work on equity and the reduction of health inequalities, because we clearly work with those who need it most.”

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